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1 of 5 Subcontractor Prequalification Questionnaire

Thank you for your interest in LEMA Construction. In order to best match your capabilities with upcoming opportunities, please fill out the following information and either return to LEMA's Office, Email: [email protected], or fax 727-570-8640

Subcontractor Prequalification Questionnaire

1. Legal Company Name:

2. Mailing Addresses:

3. Business phone:

6. Number of Employees: Are Any LEED Accredited:

4. Company Established (Month/Year):

5. Form of Business (check all that apply): Sole Proprietorship

SBE

Partnership

MBE

Corporation

WBE Other:

Contact Name and Email:

Business fax:

Website:

Federal Tax Id Number: Current Licenses:

General Information:

Safety Information:

7. Indicate your EMR for the current year and two previous years:Current: Last: Prior to Last:

8. OSHA:a. Are your employees 10-hr OSHA Certified. If yes, how many and the positions that are trained:

b. Are your employees 30-hr OSHA Certified. If yes, how many and the positions that are trained:

Yes

Yes

No

No

9a. Experience - Scope of Work (Check all that apply):

Work Experience:

Div. 07 – Roofing/SidingDiv. 08 – Doors/Windows Div. 09 – FinishesDiv. 10 – FixturesDiv. 11 – EquipmentDiv. 12 – Furnishings

Div. 13 – Special ConstructionDiv. 14 – Elevators/LiftsDiv. 21, 22, 23 – MechanicalDiv. 26, 27, 28 – Electrical

Other (specify below):

Div. 01 – General RequirementsDiv. 02 – Site DevelopmentDiv. 03 – ConcreteDiv. 04 – MasonryDiv. 05 – Metals Div. 06 – Carpentry


Of the scope of work from question 9a., please complete the following information for further evaluation. (You may use the "Additional Blank Pages" at the end of this form)

9b. Experience - Overall:

9c. Experience - Completed Projects:

List five (5) most recent and similar projects completed, starting from the most recent completion date. You may include projects where the bidder (your company) and subcontractor were subcontractors.

- Contact Name: - Contact Phone #

Dollar Amount: $ Contract Completion Date:

3 Project Name:

Contractor:

SBE, MBE, or WBE:



5 Project Name:

Contractor:

SBE, MBE, or WBE:



2 Project Name:

Contractor:

SBE, MBE, or WBE:



4 Project Name:

Contractor:

SBE, MBE, or WBE:


Division/Trade: Business Name Under Which Trade is/was Performed: Years Performing Trade Under this Name:


1 Project Name:

Contractor:

SBE, MBE, or WBE:


List your company’s facilities and major equipment, leased or owned. (You may use the "Additional Blank Pages" at the end of this form)

9d. Experience - Facilities and Equipment:

Regulatory / Contractual:

10. Recent Occurrences:

If relevant to your company, include an explanation of all occurrences from the list below that have taken place in the last 5 years, orindicate "no" if irrelevant. (You may use the "Additional Blank Pages" at the end of this form, as needed) Provide sufficient and appropriatedetail information such as "project name, owner, contact person and contact phone number, and amount of contract, etc."

• Any judgments, claims or suits pending or outstanding against your company?If yes, include a brief explanation of each.

• Any citations by OSHA for violations in the last five (5) years?If yes, please include list of violations, status, and fine amount.

• Any judgments, claims or suits pending or outstanding against a client or general contractor?If yes, include a brief explanation of each.

• State or Federal Prevailing Wage violations or judgments?If yes, please include list of violations and status.

Yes No

Yes No

Yes No

Yes No

Company Policies and Statistics:

11. Does your company have workers compensation through the State of Florida?

If yes, please include your current certificate. If no, please explain. (You may use the "Additional Blank Pages" at the end of this form)

Please include your current bonding certificate(s) of insurance.

Yes No

12. Insurance Information:

Insurance Type Insurance Company Limits Date of Renewal

Automobile

Employers Liability

General Liability

Excess Insurance

Bonding Company Bonding Capacity


• Been required to issue joint party checks to you and your suppliers or subcontractor?If yes, include a brief explanation of each. You can use "Additional Blank Pages" at the end of this form.

• Been assessed liquidated damages for late completion of a project within the last three (3) years?If yes, include a brief explanation of each.

• Been associated with or worked for LEMA under your current or another company name?If yes, under which company name?

• Previously worked on a LEMA project?If yes, list up to five (5) most recent projects.

Add additional pages if desired.

16. Has your company:

Yes No

Yes No

Yes No

Yes No

This information is not a public record under Ohio Revised Code Section 149.43; and shall remain confidential,except under proper order of a court.

Company Associations:

Financial:

17. Projected Annual Sales: $ 18. Current Uncompleted Backlog $

19. Are you willing to provide the following information, if required?a. An annual financial statement prepared within the 12 months prior to the prequalification request by

an independent licensed accounting firm; and the name, address, contact person and phonenumber of the bank normally used by the Bidder for its primary banking;

b. A financial report generated from Standard and Poor, Dun and Bradstreet or a similar company acceptable to LEMA documenting the financial condition of the Bidder; and the name, address, contact person andphone number of the bank normally used by the Bidder for its primary banking;

Yes

Yes

No

No

Thank you for completing the Subcontractor Prequalification Questionnaire for LEMA Construction.

• Training/orientation on sexual harassment in the workplace?• A written Disciplinary Policy?• A written Hazardous Communication Program?• Safety orientation for new hires?• Mandatory weekly safety meetings?• A designated Safety Officer for your company?• A Substance Abuse Policy?• Pre-hire Testing?• Post-hire/Random Testing?

13. Does your company have:

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes NoYes No

14. Employee Compliance:Are you willing to require your employees to be subjected to site, project, or Owner specific drug and/or alcohol testing programs? Yes No

(You may use the "Additional Blank Pages" at the end of this form as needed, or include your own documents.)

I certify that the information in this questionnaire is correct and complete.

Signature:

Name of Company Principal (print)

Signature of Company Principal Date

1.

2.

3.

4.

5.

Subcontractor Prequalification Questionnaire Additional Blank Pages

Please precede your responses with the question number you are addressing.

Subcontractor Prequalification Questionnaire - Additional Blank Pages5 of 5

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